23 British Journal of Midwifery January 2014 Vol 22, No 1

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Using antimicrobial Surgihoney to
prevent caesarean wound infection
C
aesaiean seciion (CS) is a common
opeiaiion in obsieiiic piaciice.
Tleie las been a naiional inciease
in Caesaiean wound infeciion (S-:(.6%)
(Naiional Insiiiuie foi Healil and Caie
Excellence (NICE), :oii; Paianjoily ei al,
:oo; NHS Infoimaiion Ceniie foi Healil and
Social Caie , :ooq) and a wide vaiiaiion acioss
NHS lospiials (ianging fiom i.6 io i.q%)
associaied wiil ile i(y y:6 cases of CS eacl yeai
in ile UK (Biagg ei al, :oio). A ieceni suivey
slowed a naiional aveiage wound infeciion
iaie of q.6% (Wlocl ei al, :oi:a). Caesaiean
wound infeciion is a majoi cause of piolonged
lospiial siay, iesouice consumpiion, as well
as oilei moibidiiies and moiialiiy. Recoveiy
fiom CS is moie difficuli foi women wlo develop
posi-opeiaiive wound infeciion (Wlocl ei al,
:oi:a). In ieims of ile buiden on lealil-caie
iesouices, ile cosi of eacl case of CS infeciion
las been esiimaied io be beiween coo and
moie ilan ciy ooo, depending on seveiiiy (Wlocl
ei al, :oi:b)
Suigiloney
TM
(Healing Honey Inieinaiional,
UK) is a licensed sieiile pioduci wlicl las been
developed foi wound caie and as a pioplylaciic
diessing foi wounds. Ii consisis of loney
wlicl las been modified io pioduce diffeieni
poiencies of aniimiciobial aciiviiy. Iis poiency
is compaiable io clemical aniisepsis bui ii
ieiains ile wound lealing piopeiiies of naiuial
loney (Aimsiiong, :ooq; }ull ei al, :oi).
Suigiloney is liglly aciive againsi giam-posiiive
and giam-negaiive bacieiial wound isolaies
(Diyden ei al, :oi). Minimum inlibiioiy and
bacieiicidal conceniiaiions aie well below ile
conceniiaiion of Suigiloney in ile wound
(Diyden ei al, :oi).
Tlis papei iepoiis a seivice evaluaiion
developed because of concein aiound ile
naiional iepoiiing of iising CS infeciion. Iis
aim was io esiablisl wleilei Suigiloney,
applied io ile wound ai opeiaiion, lad any
effeci on piomoiing wound lealing and ieducing
posi-CS wound infeciion. A cosi-effeciiveness
analysis was modelled aiound ile clinical
daia in line wiil inieinaiional consensus
(Huseieau ei al, :oi).
Mcthods
Clinical Evaluaiion
Tle evaluaiion was an obseivaiional siudy wiil
iempoial compaiison of CS suigical siie infeciion
(SSI) iaies. Ii was piimaiily a seivice evaluaiion
foi ile use of Suigiloney aniimiciobial diessing.
Tle Hampsliie Hospiials NHS Foundaiion
Tiusi's ieseaicl and developmeni commiiiee was
consulied in ile piepaiaiion of ilis evaluaiion.
Tle piojeci was classified as a seivice evaluaiion,
using a licensed pioduci foi iis appioved
indicaiion as paii of iouiine clinical caie. Tle
siudy involved colleciing anonymised daia in
ielaiion io ile inieiveniion.
All women giving biiil by CS ai ile Royal
Hampsliie Couniy Hospiial in Winclesiei
beiween Ociobei :oi: and }anuaiy :oi weie
offeied Suigiloney as a single applicaiion wound
diessing ai ile end of ile pioceduie. Conseni was
obiained fiom eveiy paiiicipani. Eacl iog saclei
of Suigiloney was foi single paiieni use. Using
an asepiic ieclnique, a 'non-sieiile' opeiaiive
assisiani opened ile Suigiloney saclei and
caiefully applied ile sieiile conienis onio ile
sieiile diessing. Tle diessing was ilen applied
io ile suigical wound by ile obsieiiician oi
ileaiie midwife. Women weie also given iouiine
single dose aniibioiic pioplylaxis aiound ile
Abstract
Caesarean section (CS) wound infection rates are unacceptably high
(around 10% according to figures from the Health Protection Agency
(2012)). This service evaluation assessed the effects of Surgihoney
on surgical site infection rates in women undergoing caesarean
section. All women presenting for CS were offered Surgihoney as a
single application wound dressing at the end of the procedure. All
women were followed up and examined for surgical site infection for
30 days after CS. A single application of Surgihoney dressing reduced
surgical site infection (SSI) by 60.33% from a rate of 5.42% (n=590)
to 2.15% (n=186) (p-value=0.042). The potential saving to the NHS of
using Surgihoney as a single-application achieving this level of wound
infection reduction is considerable. Surgihoney offers a simple, cost-
effective intervention to reduce SSI in women undergoing CS. It is
applicable to practice in all health economies and could potentially
save considerable surgical infective morbidity in patients undergoing
surgical delivery.
Matthew Dryden
Consultant in Infection
and Microbiology
Hampshire Hospitals
NHS Foundation Trust
Clare Goddard
Midwife
Hampshire Hospitals NHS
Foundation Trust
Aznvik Madadi
Midwife
Hampshire Hospitals NHS
Foundation Trust
Michael Heard
Consultant Obstetrician
Hampshire Hospitals NHS
Foundation Trust
Kordo Saeed
Consultant Microbiologist
Hampshire Hospitals NHS
Foundation Trust
Jonathan Cooke
Professor
Centre for Infection
Prevention and
Management, Imperial
College London
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some women weie given aniibioiic pioplylaxis
piioi io slin incision and some ai clamping of
ile coid. An analysis of women wiil CS wound
infeciion in boil coloiis slowed no significani
associaiion beiween aniibioiic pioplylaciic dose
iiming and CS SSI.
Posi-opeiaiively, wound claiacieiisiics
weie iecoided by ile aiiending midwife in ile
clinical quesiionnaiie (Toble i). Foui women
oui of iS6 weie iepoiied io lave a CS SSI
duiing ile evaluaiion (Toble :). Tlis iepiesenied
an infeciion iaie of :.i %. A single paiieni
iepoiied an adveise eveni ielaied io Suigiloney
iieaimeni in ile foim of wound iiiiiaiion wlicl
iesolved wiiloui fuiilei inieiveniion in days.
In ile pieceding q monils, ileie weie qo
CS pioceduies (:( eleciive and 6 emeigency)
caiiied oui ai ile lospiial and obsieiiic
infeciion coniiol suiveillance iecoided : CS SSI,
iepieseniing an infeciion iaie of .(:% (Toble ).
Tle 6o% ieduciion in infeciion iaies is significani
(p-value=o.o(:;
:
iesi).
Economic evaluaiion
In ile calendai yeai of :ooS in ile UK, among
6:o 6o( singleion biiils, ileie weie i(y y:6
(:.S%) infanis deliveied by CS (Biagg ei al,
:oio). A piospeciive mulii-ceniie coloii siudy in
:ooq found ilai q.6% of CS women developed
a posi-suigical infeciion (Wlocl ei al, :oi:a).
Exiiapolaiion of ilese iaies naiionally would
piedici an expecied numbei of i( iS: cases of SSI.
As ile iepoiied esiimaied aveiage individual cosi
of CS SSI is c6oo (iange coo io moie ilan ciy,ooo)
(Wlocl ei al, :oi:b) ilen ile coiiesponding
naiional annual economic buiden in ile UK is
ileiefoie cS oq oiy.
Sensiiiviiy analysis
Tle wound infeciion iaies fell by 6o% wlen
Suigiloney was used. If ilis level of ieduciion
could be iepeaied naiionally ilen ileie would be
a ieduciion in ile numbei of CS SSI fiom i( iS:
io 6y:. Tlis would mean ilai ileie would be a
poieniial naiional annual cosi saving io ile NHS
of c io (oo.
Using ile SSI daia fiom ile iwo aims of ile
evaluaiion (ile fiisi q monils pie-inieiveniion
and ile monils posi-inieiveniion), CS SSI iaies
(expecied) weie .(:% befoie Suigiloney and
(obseived) :.i% afiei. Ai ilese levels, wlicl aie
lowei ilan ile iaies of infeciion pieviously iepoiied
ai q.6% (Wlocl ei al, :oi:a), ile exiiapolaied CS
SSI infeciions iaies foi UK would be (expecied)
Sooy cases pei yeai and (obseived) iy6 cases pei
yeai. Tle diffeience is (Si cases of CS SSI ilai
CS. Tle iiming of ile aniibioiic pioplylaxis was
noi unifoimsome weie adminisieied ai slin
incision, some afiei coid clamping.
Afiei ile pioceduie, ile aiiending midwife
compleied an evaluaiion iecoid. Daia collecied
weie MRSA siaius, lisioiy of diabeies,
medicaiions, and body mass index (BMI). Foi i(
days afiei ile pioceduie, ile aiiending midwife
in ile communiiy also iecoided any wound
lealing pioblems, specifically ile piesence
of oozing, pain and inf lammaiion. If ileie
was any inf lammaiion, a wound culiuie swab
was iequesied and miciobiological iesulis
weie iecoided. Tle women weie given a posial
quesiionnaiie oi weie ieleploned foi follow-up
ai o days afiei ile CS.
SSI was defined as ile piesence of clinical signs
and]oi aniibioiics piesciibed. Clinical signs lad io
compiise ai leasi iwo of pain, eiyilema, swelling
and pus disclaige ai ile opeiaiive siie.
Tle SSI iaie duiing ile monils of ile
evaluaiion using ile Suigiloney diessing was
compaied wiil ile infeciion iaie in ile q
monils piioi io ile evaluaiion, based on daia
also collecied by ile obsieiiic ieam wiil ile
infeciion coniiol depaiimeni using ile same
clinical ciiieiia. Infeciion iaie daia was collecied
foi a full yeai, wiil ile Suigiloney inieiveniion
occuiiing in ile final monils, lence ile fiisi
q monils daia weie compaied wiil ile final
monils afiei ile Suigiloney inieiveniion. Tle
iaie of SSI was calculaied as a peiceniage of all
CS pioceduies caiiied oui.
Economic evaluaiion was modelled on
publisled aveiage iaies of CS SSI (Wlocl ei al,
:oi:a), of cosis associaied wiil CS SSI (Wlocl ei
al, :oi:b) and ile obseived diffeiences in CS SSI
iaies in ile siudy. An aveiage esiimaied cosi foi
eacl CS SSI was deieimined io be c6oo (iange
coo io moie ilan ciy,ooo) (Wloclei al, :oi:b).
Rcsu!ts
In ile -monil peiiod, Ociobei :oi: io }anuaiy
:oi, ileie weie iS6 CS pioceduies caiiied oui ai
ile lospiial, of wlicl io: (%) weie emeigencies.
No women weie colonised wiil MRSA. Foui
(:.:%) lad diabeies melliius and (: (:y.%) lad
a BMI of moie ilan :.
Single dose aniibioiic pioplylaxis was given
ai eveiy CS pioceduie in addiiion io ile
Suigiloney diessing. Howevei, iiming of ile
aniibioiic dose was noi unifoim iliougloui ile
yeai duiing ile iwo siudy peiiods of q monils
pie inieiveniion and monils posi inieiveniion.
Tlis may ileiefoie lave been a confounding
facioi. Tle iiming depended on ile anesileiisi;
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could poieniially be ieduced and ileiefoie ile
poieniial ioial cosi ilai could be saved by ile NHS
by using Suigiloney as a CS wound diessing would
be c: SqS 6oo pei annum. Tle cosi of Suigiloney
is noi lnown, bui ii is a simple, low-ieclnology
inieiveniion. If ile cosi pei applicaiion was an
addiiional c io ile diessing, ilen ile cosi of
eveiy CS ieceiving Suigiloney would be cyS 6o
pei annum.
Discussion
Tlis evaluaiion demonsiiaied ilai Suigiloney,
a liglly effeciive aniimiciobial wound diessing
(Diyden ei al, :oi), can be employed as a wound
diessing of piimaiy CS wounds io pieveni
infeciion. As a 'naiuial' pioduci wiil esiablisled
wound lealing piopeiiies, Suigiloney is lilely io
piomoie wound lealing in addiiion io pioviding
poieni aniimiciobial aciiviiy io pieveni wound
colonisaiion and infeciion. Some lalogen-based
clemical aniisepiics may piovide ile same
degiee of aniimiciobial aciiviiy bui may delay
wound lealing (}an ei al, :oi:). Howevei, iodine
wound diessings aie coniiaindicaied in CS (}oini
Foimulaiy Commiiiee, :oi) and a iange of
ioxiciiies aie associaied wiil ileii use (Pieiscl
and Mealins, iqy6; Scoggin ei al, iqyy; Zec
ei al, iqq:; Colpaeii ei al, :ooq; Ramaswamylanive
ei al, :oii; Lallal ei al, :oii). Similaily, a
Cocliane Sysiemaiic Review slowed ileie was
insufficieni evidence io esiablisl wleilei silvei-
coniaining diessings oi iopical agenis piomoie
wound lealing, pieveni wound infeciion (Sioim-
Veislooi ei al, :oio) oi aie effeciive iieaimenis
of infecied oi coniaminaied clionic wounds
(Veimeulen ei al, :oio).
In a compaiison of wound infeciion iaies ovei
iwo iime peiiods, ile evaluaiion las slown a 6o%
ieduciion in infeciion iaies fiom .(:% piioi io ile
inieiveniion ,io :.i% using Suigiloney.
Siiengils and limiiaiions
Caesaiean wounds weie closen in ilis evaluaiion
because ile paiienis aie by and laige lealily wiil
no, oi veiy few, co-moibidiiies, and CS infeciion
iaies aie iepoiied io be incieasing (NICE, :oii;
Paianjoily ei al, :oo; NHS Infoimaiion Ceniie
foi Healil and Social Caie, :ooq). Possible
ieasons foi ilis iise lave been incieases in
oldei moileis, moileis wiil co-moibidiiies,
paiiiculaily diabeies, and moileis wiil
liglei BMIs (Naiional Insiiiuie foi Healil
and Caie Excellence, :oii; Healil Pioieciion
Agency, :oi:). Wlile ii las noi pieviously
been iouiine io use an aniimiciobial ageni in
ile piimaiy wound diessing, ilis evaluaiion
las slown an inieiesiing and effeciive
iole foi Suigiloney in ile pieveniion of CS
wound infeciions.
Tle limiiaiion of ilis evaluaiion is ilai ii
was noi a iandomised coniiolled siudy and used
ieiiospeciive compaiisons. Howevei, a ieceni
well-coniiolled siudy of a vaiieiy of suigical
ieclniques in CS slowed liiile diffeience in
a composiie of deail, maieinal infeciious
moibidiiy, fuiilei opeiaiive pioceduies oi blood
iiansfusion up io ile 6-weel follow-up visii
(CORONIS Collaboiaiive Gioup, :oi). Fuiilei
iandomised coniiolled siudies of ile use of
Suigiloney io pieveni SSI in diffeieni suigical
Table 1. Adverse events in wound healing in Surgihoney patients
Wound characteristic Number %
Oozing 5 2.68
Pain 7 3.76
Inflammation 5 2.68
Positive microbiology 4 2.15
Antibiotics required 4 2.15
Wound healing delay after 10 days 1 0.53
Wound infection (met the case definition of infection 4 2.15
Table 2. Microbiology of infected caesarean section wounds
in the Surgihoney group
Patient Microbiology Clinical comments
1 Heavy growth
Enterococcus sp. and
mixed anaerobes,
scanty Candida albicans
Erythema, oozing wound,
oral antibiotics, body
mass index (BMI) 31
2 Moderate growth
Streptococcus milleri
and anaerobes
Pain, Purulent Dx, oral
antibiotics, BMI 32
3 Culture not done Redness and some
oozing, antibiotics
prescribed, BMI 22.4
4 Moderate growth of
Staphylococcus aureus,
+ anaerobes
Erythema, oozing
wound, pain, oral
antibiotics
Table 3. Caesarean section numbers and infection rates
Period Total
number of
caesarean
sections
Elective
(%)
Emergency
(%)
Number
of surgical
site
infections
Infection
rate
Jan 2012
Sept 2012
590 234
(39.7%)
356
(60.3%)
32 5.42%
Oct 2012
Jan 2013
186 84 (45.2%) 102
(54.8%)
4 2.15%
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Sucl an advance would assisi ile ieduciion of
aniibioiic volume use and ile seleciion piessuie
on colonising bacieiia. Fuiilei siudies would
cleaily be needed io suppoii ilis appioacl.
Conc!usion
Pieveniion of infeciion of wounds wiil Suigiloney,
an ageni wlicl is noi ioxic io lealing iissue and
also piomoies ile lealing piocess, is a novel and
poieniially impoiiani finding wlicl may clange
ile way ilai suigical wounds aie managed. Tle
findings in ilis siudy siiongly suppoii ile need
foi fuiilei siudies on ile effecis of Suigiloney on
suigical wounds. BJM
AcknowleJqemens: Tbe outbors woulJ like to tbonk tbe
obstetrics onJ miJwifery teom ot Hompsbire Hospitols
FounJotion Trust onJ tbe new motbers for tbeir support,
encouroqement onJ contributions to tbis evoluotion onJ
recorJinq of clinicol Joto. Tbonks olso to tbe infection
control teom ot tbe Royol Hompsbire County Hospitol for
tbeir Joto on coesoreon wounJ infection. Tbis stuJy wos
supporteJ by Heolinq Honey lnternotionol wbo proviJeJ tbe
proJuct. Tbere wos no oJJitionol funJinq.
Dsclosure oj neres: Hompsbire Hospitols NHS
FounJotion Trust bos receiveJ funJinq from Heolinq Honey
lnternotionol UK for in-vitro loborotory work unreloteJ to
tbis stuJy.
Aimsiiong DG (:ooq) Manula loney impioved wound
lealing in paiienis wiil slougly venous leg ulceis.
EviJence-boseJ MeJicine I(): i(S
Asiagneau P, Rioux C, Gollioi F, Biclei G; INCISO
Neiwoil Siudy Gioup (:ooi) Moibidiiy and moiialiiy
associaied wiil suigical siie infeciions: iesulis fiom
ile iqqy-iqqq INCISO suiveillance. journol of Hospitol
lnfection 8((): :6y-y(
Baglel PS, Slulla S, Mailui RK, Randa R (:ooq) A
compaiaiive siudy io evaluaie ile effeci of loney diessing
and silvei sulfadiazene diessing on wound lealing in buin
paiienis. lnJion journol of Plostic Surqery i(:): iy6-Si
Biagg F, Ciomwell DA, Edozien LC, Guiol-Uiganci I,
Malmood TA, Templeion A, van dei Meulen }H (:oio)
Vaiiaiion in iaies of caesaiean seciion among Englisl
NHS iiusis afiei accouniing foi maieinal and clinical
iisl: Cioss seciional siudy. BMj I: co6
Colpaeii K, Tiomp F, Vandecasieele E, Dlondi A, De Waele
}, Hosie E, Deciuyenaeie }, Monsiiey S (:ooq) Iodine
ioxiciiy as a cause of ioial aiiioveniiiculai blocl in buin
paiienis. Burns (Supplemeni i): S(-S(6.
CORONIS Collaboiaiive Gioup, Abalos E, Addo V,
Bioclleluisi P, El Sleill M, Faiiell B, Giay S, Haidy P,
}uszczal E, Mailews }E, Masood SN, Oyaizun E, Oyiele
}, Slaima }B, Spail P (:oi) Caesaiean seciion suigical
ieclniques (CORONIS): A fiaciional, facioiial, unmasled,
iandomised coniiolled iiial. loncet 8i(qSSS): :(-(S
Diyden M, Hudgell L, Saeed K, Diyden AWS, Biools },
Coole } (:oi) Surqiboney - EnqineereJ boney wounJ
pioceduies aie waiianied. A fuiilei limiiaiion
is ile vaiiabiliiy in iiming of aniibioiic
pioplylaxis aiound ile CS. Analysis of CS
SSI cases in boil aims, slowed no significani
diffeience in aniibioiic pioplylaxis iiming
and so ilis vaiiaiion is noi believed io be a
confounding facioi.
Inieipieiaiion
If ilis CS SSI iaie ieduciion of 6o% could be
deliveied iliougloui ile NHS by ilis simple
inieiveniion, consideiable lealil qualiiy
impiovemenis could be aclieved: a ieduciion in
aniibioiic use and subsianiial cosi savings.
Healil-caie-associaied infeciions aie a
significani and cosily lealil-caie complicaiion,
accouniing foi aiound S% of paiienis in lospiial
wiil i(% of ilese infeciion aiiiibuied io SSIs
(Smyil ei al, :ooS). Neaily % of paiienis wlo
lad undeigone a suigical pioceduie weie found
io lave developed an SSI (Smyil ei al, :ooS).
SSIs aie associaied wiil consideiable moibidiiy
and ovei a iliid of posi-opeiaiive deails aie
ielaied, ai leasi in paii, io SSI (Asiagneau ei al,
:ooi). Aniimiciobial pioplylaxis is iouiinely
employed in many suigical pioceduies io
ieduce suigical wound infeciion. Wlile slin
disinfeciion is also iouiinely used by suigeons
io ieduce ile slin bacieiial load piioi io slin
incision, ii las noi been iouiine piaciice io
use aniimiciobial diessings (Naiional Insiiiuie
foi Healil and Caie Excellence (NICE), :ooS).
A ieason foi ilis may be ilai mosi iopical
aniisepiics lave a deleieiious effeci on iissue
lealing (Baglel ei al, :ooq; Sioim-Veislooi ei al,
:oio; Hoon ei al, :oi). Suigiloney is a pioduci
wiil poieni aniimiciobial aciiviiy, wlicl also
appeais non-ioxic and may indeed piomoie
iissue lealing (Diyden ei al, :oi). Ii is iempiing
io speculaie wleilei an aniimiciobial, non-ioxic,
iissue lealing ageni applied iopically io 'clean'
suigical wounds could aciually ieplace sysiemic
aniibioiic pioplylaxis in ceiiain iypes of suigeiy.
Key points
Caesarean section wound infection rates are unacceptably high
Surgihoney is a novel honey preparation with unique action which should
not be confused with other medicinal honeys
Surgihoney has potent antimicrobial activity and can be used as a
wound dressing
In this evaluation, Surgihoney was used as a single dose at dressing of
the caesarean section wound
This intervention was associated with a reduction in caesarean section
wound infection rate by 60%
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treotment. First report of in vitro octivity onJ eorly
clinicol evoluotion. Absiiacis of ile Fedeiaiion of
Infeciion Socieiy Confeience, ICC, Biiminglam
Healil Pioieciion Agency (:oi:) Risk of infection from
coesoereons ot neorly io percent. www.lpa.oig.ul]
NewsCeniie]aiionalPiessReleases]:oi:PiessRelea
ses]i:oSoiInfeciioniislfiomcseciion] (accessed :y
}anuaiy :oi()
Hoon R, Rani A, Najafi R, Wang L. Debabov D (:oi)
Aniimiciobial aciiviiy compaiison of puie lypoclloious
acid (o.oi%) wiil oilei wound and slin cleanseis
ai nonioxic conceniiaiions. VounJ Repoir onJ
Reqenerotion iI: A:y.
Huseieau D, Diummond M, Peiiou S, Caiswell C, Molei
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